Standards › Standard 2 › Standard operating procedures (SOPs)
Standard operating procedure (SOP) · SRG-SOP-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 2.1
At a glance
- Use the WHO checklist for every procedure, at all three pauses.
- The checklist is read by a team member, not by memory.
- A missing item stops the procedure until it is resolved.
- Record each pause on the checklist record.
- Stop and get help straight away if: a missing item (identity, site, antibiotic, counts or equipment) is not resolved before the procedure starts.
1. Purpose
To run the checklist the same way in every theatre, every time (2.1).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
The surgical safety checklist works only when the team says it out loud, together, at each pause. A checklist filed after the operation protects no one.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Scrub nurse | Reads the checklist aloud and records the answers | Theatre nurse |
| Surgeon | Confirms the procedure and site | Surgeon |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Prepare.
- Check the consent form, the site marking and the imaging are available before the patient enters the theatre.
Key point: Ready before the pause.
Step 2. Read aloud.
- Read each item aloud and wait for the answer.
- Record the answer on SRG-FRM-001.
Key point: Aloud, every item.
Step 3. Stop on a gap.
- If an item is not met, do not start. Resolve it and read the item again.
Key point: A gap stops the operation.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Checklists fully completed | 100% | Monthly | Theatre manager | Escalate to chief executive |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| SRG-FRM-001 | Surgical safety checklist record | Record |
| HOS-REG-004 | Rehearsal and drill record | Drill |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO Surgical Safety Checklist (2009). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)